Center for Chronic Care Innovation

About

The goal of our Center for Chronic Care Innovation is to improve the quality of chronic disease care and prevention. We conduct clinical trials and observational studies focusing on hypertension, diabetes, depression, and other chronic diseases. We translate research evidence into practice, including through the use of clinical decision support (CDS).

Overview

abbreviation

  • CCCI

    • Affiliation

    people

    Faculty Position
  • Appana, Deepa, Director, Institute Technology 2007 -
  • Crain, Lauren, PhD, Sr. Research Investigator & Statistician 2001 -
  • Ekstrom, Heidi L., Principal Project Manager
  • Kharbanda, Elyse O., MD, MPH, Sr. Investigator 2010 -
  • Margolis, Karen L., MD, MPH, Sr. Investigator

    • Publications While At HealthPartners

    selected publications

    Journal Article
  • 'Do they care?': a qualitative examination of patient perspectives on primary care clinician communication related to opioids in the USA. 
    BMJ open. 2025
  • COVID-19 and completion of select routine childhood vaccinations. 
    Pediatrics. 2025
    Article has an altmetric score of 73
  • COVID-19 vaccine hesitancy and uptake among firefighters: an application of the Health Belief Model. 
    Journal of Occupational and Environmental Medicine. 2025
    Article has an altmetric score of 1
  • Cardiometabolic risk in pediatric patients with intellectual and developmental disabilities. 
    American Journal of Preventive Medicine. 2025
    Article has an altmetric score of 3
  • Care coordination in primary care: views of clinicians and clinic leaders. 
    Journal of Nursing Care Quality. 2025
    • Editorial Article
  • Insulin management in patients with diabetes receiving hemodialysis: unanswered questions and way forward [editorial]. 
  • Screening for suicide risk is predicting the future, not diagnosing the present [editorial]. 
    Joint Commission journal on quality and patient safety.  49. 2023
  • COVID-19 mRNA vaccines during pregnancy: new evidence to help address vaccine hesitancy [editorial]. 
  • Get a doctor to avoid going to the doctor. 
    MinnesotaSpokesmanRecorder.  2022
  • Reporting on and reviewing for race/racialization, ethnicity, and culture [editorial]. 
    • Chapter
  • Comparative effectiveness of adaptive treatment strategies. 
    Targeted learning in data science: causal inference for complex longitudinal studies (Springer series in statistics). 2018
  • Quality improvement in primary care: the role of organization, systems, and collaboratives (Chapter 12). 
    Mclaughlin And Kaluzny's Continuous quality improvement in health care. 2011
  • Diabetes. 
    Chronic disease epidemiology and control. 2010
  • Healthcare provider reminder systems, provider education, and patient education: working with healthcare delivery systems to improve the delivery of tobacco-use treatment to patients--an action guide. 
    In: The community health promotion handbook: action guides to improve community health. 2008
  • How to organize the practice for improved delivery of clinical preventive services. 
    Health promotion and disease prevention in clinical practice. 2008
    • Conference Paper
    *** hidden publications ***
  • Complications of Work Related Injury with Retained Lead Bullet Fragments in Woman of Childbearing Age
    2023
  • Complications of work related injury with retained lead bullet fragments in woman of childbearing age
    2023
  • Diabetes "smart" registries: context, complexity, and impact
    2019
  • Transforming primary care clinics into health care homes in Minnesota: what have we learned? TheTransforMN Study [keynote presentation]
    2013
  • Cost-effectiveness of EMR-based clinical decision support [presentation
    2011
    • Conference Poster
  • Understanding COVID-19 vaccine hesitancy among firefighters: application of the Health Belief Model [poster]
    2023
  • Elevated blood pressure and risks for progression to hypertension in youth 10-17 years of age [poster]
    2019
  • Factors associated with Diabetes Prevention Program (DPP) compliance and weight loss among low-income participants [poster]
    2019
  • Initial phase results of Firefighter Cardiorespiratory Fitness Pilot Study [poster]
    2019
  • Highly motivated population provides two successful recruitment methods into the TMD self-care study and PACT program [poster]
    2018
    • Report
  • Comparing telehealth and clinic-based care for lowering uncontrolled high blood pressure
    2021
    Article has an altmetric score of 6
  • Leveraging health communication, data, and innovative approaches for sustainable systems-wide changes to reduce the prevalence of obesity: proceedings of a workshop in brief
    2021
    Article has an altmetric score of 4
  • Influenza immunization for adults 18 years and older
    2017
  • Screening for depression in adults: an updated systematic evidence review for the US Preventive Services Task Force: Evidence Synthesis No. 128
    2016
  • Meningococcal immunization
    2015
    • Review
  • Factors associated with increased health care utilization for patients with dementia with Lewy bodies: a narrative review [review]. 
  • Early patient-centered outcomes research experience with the use of telehealth to address disparities: scoping review [review, systematic review]. 
  • Evidence and recommendations on the use of telemedicine for the management of arterial hypertension: an international expert position paper [review]. 
  • Screening for cognitive impairment in older adults: updated evidence report and systematic review for the US Preventive Services Task Force [systematic review]. 
  • Self-monitoring of blood pressure in patients with hypertension-related multi-morbidity: systematic review and individual patient data meta-analysis [meta-analysis, systematic review]. 
    • Policy Briefs
  • Health and well-being
    2018
    • Abstract
  • Evaluation of race and ethnicity and pharmacy dispensing of sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists in patients with type 2 diabetes [abstract]. 
    Circulation. 2024
  • Comparing change in systolic blood pressure with clinic-based care versus telehealth care in a pragmatic cluster-randomized trial (Hyperlink 3) [abstract]. 
  • Comparing two approaches to implementing suicide risk identification models [abstract]. 
  • Demographic and psychosocial factors associated with suicide mortality among childbearing-age individuals: a case-control study [abstract]. 
  • Health diagnoses and service utilization in the year prior to youth and young adult suicide [abstract]. 
    • Audio Document
  • Equity and education in the community [podcast]
    2022
    • Audio-Visual Document
  • Practice vs accountability in diabetes care
    2011
    • Book
  • Two-dimensional scan statistics for assessing vaccine safety in pregnancy (PRISM)
    2016
    • Document
  • Community consultation and public disclosure: the ResQ Trial experience
    2007
  • Depression diagnosis is related to number of outpatient visits in diabetes and non-diabetes patients
    2007
  • Diabetes care is no better in clinics that use electronic medical records (EMR)
    2007
  • Do publicly reported comprehensive quality measures lead to diabetes care improvement? The Minnesota experience
    2007
  • Does diabetes double the risk of depression?
    2007

    • Quick Info